An updated AAP policy statement and technical report on reducing the risk of sleep-related infant deaths reiterate previous safe sleep recommendations and offer some new guidance.
The AAP continues to emphasize the importance of placing infants on their backs in an uncluttered crib next to the parents’ bed in a nonsmoking environment. The policy and technical report also address the use of noninclined sleep surfaces, short-term emergency sleep locations, substance use, home cardiorespiratory monitors and tummy time.
The policy Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment is available at https://doi.org/10.1542/peds.2022-057990. The technical report Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths can be found at https://doi.org/10.1542/peds.2022-057991. Both are from the Task Force on Sudden Infant Death Syndrome (SIDS) and the Committee on Fetus and Newborn, and will be published in the July issue of Pediatrics.
Following is a summary of the updates and responses to common questions asked of the Task Force on SIDS.
Sleep surfaces
Use a flat, noninclined sleep surface. A crib, bassinet, portable crib or play yard should conform to the safety standards of the Consumer Product Safety Commission (CPSC).
Recent biomechanical analyses have demonstrated that sleep surfaces that are inclined more than 10 degrees from horizontal are unsafe for infant sleep. Additionally, the CPSC recently passed a rule that any infant sleep product, including those marketed for sleep or with images of sleeping infants, must meet federal safety standards for cribs, bassinets, play yards and bedside sleepers. Products that do not meet these standards (e.g., inclined sleep products, cardboard baby boxes, in-bed sleepers, baby nests and pods, and hammocks) are not recommended.
The Safe Sleep for Babies Act of 2021, signed into law May 16, bans the manufacture and sale of crib bumpers or inclined sleepers.
In emergency situations when a CPSC-approved surface is not available, an alternative device with a firm, flat, noninclined surface with thin, firm padding can be used temporarily until a CPSC-approved surface is available.
Sleep location
Infants should sleep in the parents’ room, close to the parents’ bed but on a separate surface designed for infants, ideally for at least the first six months.
The AAP has shortened the period recommended for room-sharing. Although it is difficult to stratify the data based on age in months, the AAP recognizes that the highest risk is in the first six months (when 90% of sudden and unexpected infant deaths occur).
Bed-sharing
Although the AAP cannot recommend bed-sharing based on the evidence, it also respects that many parents choose to bed-share routinely for a variety of reasons.
It is important for clinicians and parents to have frank and nonjudgmental discussions about the family’s bed-sharing circumstances. The policy provides a risk-stratification analysis to guide these discussions.
Because of the extreme (up to 67 times greater) risk, the AAP strongly recommends that infants never be placed for sleep, with or without another person, on a couch, sofa, armchair and similar cushioned surfaces (despite the multitude of pictures posted on social media of adults sleeping with a baby on their chest on a sofa).
Bedding
Do not place any soft objects, including pillows, blankets or bumper pads, in the infant’s sleep environment.
Families concerned that their infant will be cold should add layers of clothing, as this reduces the risk of head covering or entrapment. Wearable blankets or sleepers also can be used. The AAP does not recommend any weighted objects (e.g., weighted blankets/sleepers/swaddles) on or near a sleeping infant.
Pacifiers
Pacifier use is associated with a reduced risk of SIDS.
For infants who are not directly breastfed, pacifiers can be introduced at any time. For breastfed infants, the pacifier can be started once breastfeeding is firmly established — meaning that milk supply is sufficient, the infant is latching effectively and the infant has demonstrated appropriate weight gain.
Monitoring devices
Home cardiorespiratory monitors should not be used to reduce the risk of SIDS.
Wearable heart rate and pulse oximetry monitoring devices sold to consumers are certified by the Food and Drug Administration (FDA) as wellness devices, which do not meet the criteria for medical devices. They are defined as devices intended “for maintaining or encouraging a healthy lifestyle and … unrelated to the diagnosis, cure, mitigation, prevention, or treatment of a disease or condition.”
Data supporting their use to prevent sudden and unexpected death are lacking. Parents who use these monitors at home still should follow safe sleep recommendations.
Tummy time
Supervised tummy time should start soon after hospital discharge and increase slowly to at least 15-30 minutes total daily by 7 weeks of age.
Other recommendations
- Avoid smoke and nicotine exposure — and the use of alcohol, marijuana, opioids and illicit drugs — during pregnancy and after birth.
- Pregnant people should obtain regular prenatal care.
- Infants should be immunized in accordance with recommendations from the AAP and Centers for Disease Control and Prevention.
- There is no evidence that swaddling reduces the risk of SIDS.
- Physicians and others should model safe infant sleep guidance from the beginning of pregnancy.
Dr. Moon is a lead author of the policy and technical report and chair of the AAP Task Force on SIDS.
Resources
- Table 3 in the policy at https://doi.org/10.1542/peds.2022-057990 summarizes changes since 2016.
- The technical report at https://doi.org/10.1542/peds.2022-057991 provides the evidence base for the recommendations.
- Safe to Sleep campaign
- Information for parents from HealthyChildren.org on baby products to avoid
